Action Points

Be aware that HIV-infected adults may have higher diabetes (DM) prevalence at younger ages and in the absence of obesity, compared with the general US adult population.

Note that after adjusting for sex, age, obesity, and additional sociodemographic factors, investigators found that the prevalence of diabetes was 3.8% higher in HIV-infected adults than in the general population.

Patients with HIV may be more susceptible to diabetes, and the disease may strike them at a younger age and in the absence of obesity, data from two large surveys indicated.

The prevalence of diabetes among a representative sample of HIV-infected adults was 10.3% (95% CI 9.1%-11.5%), compared with 8.3% in the general population (95% CI 7.2%-9.4%), reported Alfonso Hernandez-Romieu, MD, of Emory University in Atlanta, and colleagues.

After adjusting for sex, age, obesity, and additional sociodemographic factors, the investigators found that the prevalence of diabetes was 3.8% higher in HIV-infected adults than in the general population (95% CI 1.8%-5.8%), Hernandez-Romieu and colleagues reported in BMJ Open Diabetes Research & Care.

Among HIV-infected patients, the prevalence of diabetes was 5% higher in women, 4.1% higher in those age 20-44, and 3.5% higher in non-obese individuals than in the general population, the study found.

"This analysis provides the first nationally representative estimate of DM [diabetes mellitus] burden among HIV-infected adults and suggests that HIV-infected persons may be more likely to have DM at younger ages and in the absence of obesity compared with the general U.S. adult population," the investigators wrote.

Hernandez-Romieu and colleagues noted several implications to their findings. "First, HIV-care providers should follow existing DM screening guidelines, which recommend FBG and HbA1c be obtained prior to and after starting ART [antiretroviral therapy].

"Second, existing data from prospective studies should be examined to determine if screening guidelines should be modified, given the increased prevalence of DM among younger and non-obese HIV-infected persons.

"Third, improved tests for DM diagnosis and monitoring among HIV-infected persons should be explored, given studies that have demonstrated the diagnostic limitations of HbA1c in this population," the investigators wrote.

The study included data on 8,610 HIV-infected adults from the Medical Monitoring Project (MMP), a surveillance system that produces nationally representative estimates of behavioral and clinical characteristics of HIV-infected adults who receive HIV medical care in the United States. The investigators compared these data with results from 5,604 adults in the 2009-2010 National Health and Nutrition Examination Survey (NHANES), using logistic regression analysis.

Among HIV-infected adults in the study, 3.9% had type 1 diabetes, 52.3% had type 2 diabetes, and the remaining 43.8% had unspecified diabetes.

The mechanistic link between HIV infection and diabetes risk is not clear, but possible mechanisms include the chronic inflammation associated with HIV infection as well as cumulative exposure to antiretroviral therapy, both of which have been linked with insulin resistance, Hernandez-Romieu and colleagues said.

"Despite evidence suggesting a link between ART and DM, ART prescription in the past year was not associated with prevalent DM in our study," the researchers wrote. "This may be due to our inability to assess cumulative exposure to ART in MMP. The ARTs indinavir, zidovudine, saquinavir, stavudine, and didanosine have been associated with a higher prevalence of DM; only a small percentage of HIV-infected adults in MMP were currently prescribed these agents ... which may also account for the null association between ART exposure and DM."

One limitation of the study was that the definition of diagnosed diabetes was different between the MMP (medical record abstraction) and NHANES (self-reported), which might have been a source of bias, Hernandez-Romieu and colleagues noted.

Another limitation was that risk factors for diabetes -- such as family history, diet, and exercise -- were not included in the analysis and could explain some of the excess prevalence observed among HIV-infected adults, the investigators said.

Finally, MMP data are representative of HIV-infected persons receiving medical care and do not necessarily reflect diabetes prevalence among HIV-infected persons not diagnosed or not receiving care, Hernandez-Romieu and colleagues acknowledged.

"Given the large burden of DM among HIV-infected adults, additional research would help to determine whether DM screening guidelines should be modified to include HIV infection as a risk factor for DM and to identify optimal management strategies in this population," the researchers wrote, noting that traditional strategies such as weight loss and medical therapy have been less effective among HIV-infected patients.

The study was funded by the CDC. No researchers reported financial relationships with industry.